Sexual and gender-based violence (SGBV) is a threat to women and girls' health and justice globally, and is widely prevalent in Sierra Leone. This study identifies key barriers to high-quality healthcare and justice for SGBV survivors in Sierra Leone using a gender-integrated socio-ecological model. In this qualitative study, purposive sampling was performed with maximum variation by sector and region. From December 2023 to February 2024, Sierra Leonean and international researchers conducted semi-structured interviews and focus group discussions with health, legal, law enforcement, and government officials across Sierra Leone. Data analysis employed a hybrid thematic approach using a gender-integrated socio-ecological model (GI-SEM) framework while remaining open to emerging themes. Analysis was completed between August 2024-March 2025. Across five sites in Sierra Leone, a total of 31 multidisciplinary staff participants were included through semi-structured individual (n=17) and focus group interviews (n=6), including healthcare providers (n=15; 48.4

To expand access to diagnostic breast ultrasound, experts recommend training non-radiologist clinicians. Robust strategies to assess trainee competence are needed to ensure ultrasound quality. This review sought to answer the question, “What strategies have been used to assess breast ultrasound skill?,” describe skill domains assessed, and determine whether tools’ measurement validity has been established. Following PRISMA guidelines, we searched Medline, Embase, Scopus, and Web of Science.Of 3422 records, 21 studies were included; 61.9% were from high-income countries. Skill assessment strategies included comparison to a gold standard (n = 8) and review of images with known findings (n = 6). Lesion detection and characterization and BI-RADS were the most common skills assessed. No study systematically validated a tool. Existing methods for evaluating breast ultrasound skill are varied and unvalidated. Validated tools could help optimize breast ultrasound training and quality globally.

Background Butaro Cancer Center of Excellence (BCCOE) was founded to serve Rwanda's rural low-income population, providing subsidized cancer diagnosis and treatment with transport stipends for the lowest-income patients. We examined whether travel distance to BCCOE was associated with advanced-stage diagnoses and treatment completion. Methods We conducted a retrospective cohort study using medical record data from BCCOE patients with pathologically-confirmed breast cancer from 2012-2016. Women with no prior surgery were included in the stage analysis; those with non-metastatic disease were included in the treatment analysis. We calculated travel distances using spatial analytic software and used multivariable logistic regression to examine the association of distance and other patient characteristics with late-stage diagnoses and treatment completion within one year of diagnosis. Results The analytic cohort for stage included 426 patients; 75.1% had late-stage (stage 3 or 4) disease. In univariable analyses, patients residing in BCCOE's surrounding district had a lower proportion of late-stage diagnoses compared to those residing outside the district (57.9% v 76.8%, p = 0.02). In adjusted analyses, odds of late-stage diagnosis were 2.46 (95% CI:1.21-5.12) times higher among those in distance quartile 4 (> 135.8 km) versus 1 (< 55.7 km); the effect of distance was less strong in sensitivity analyses excluding patients from BCCOE's surrounding district. Patients from sectors with > 50% poverty had 2.33 times higher odds of late-stage diagnoses (95% CI:1.07-5.26) relative to those with poverty < 30%. In the treatment completion cohort (n = 348), 49.1% of patients completed surgery and chemotherapy within a year. In adjusted analyses, travel distance and poverty were not linearly associated with treatment completion. Conclusions At Rwanda's first public cancer facility, sector-level poverty and longer travel distances were associated with late-stage breast cancer diagnoses, but less clearly associated with treatment completion, perhaps partly due to travel stipends provided to the lowest-income individuals undergoing treatment. Our findings support further investigation into wider use of travel stipends to facilitate early diagnosis and treatment completion.

PURPOSE:The National Comprehensive Cancer Network (NCCN) and American Cancer Society (ACS) endorse differing guidelines for screening breast imaging among young females with familial breast cancer risk not driven by a germline pathogenic variant (PV). We sought to characterize practice patterns in our high-risk breast clinic related to screening breast imaging in this population. METHODS:We identified all females aged 25-39 years with a first- or second-degree relative (FDR/SDR) with breast cancer and estimated lifetime breast cancer risk of ≥ 20% by the Tyrer-Cuzick (TC) version 7 model. Those with known PV in a breast cancer gene were excluded. We described provider recommendations for age to initiate screening and use of supplemental imaging modalities. RESULTS:Among 334 included patients, 218 (65.3%) had an FDR with breast cancer and 116 (34.7%) had SDRs only. Screening prior to age 40 was recommended to 233 (69.8%) patients and varied by extent of family history and age of the youngest affected relative. Only a minority (24.1-27.0%) of recommendations aligned with NCCN or ACS guidelines. For the remaining patients, 82.2% and 48.7% were recommended to initiate screening younger than the NCCN or ACS guideline, respectively. Supplemental imaging with MRI or whole breast ultrasound was offered to 219 (65.6%) patients. CONCLUSION:Even in a specialized clinic, there is substantial variation in breast imaging recommendations for young females with elevated breast cancer risk based on family history. As formal risk assessment is increasingly adopted in clinical practice, this population should be a priority for future screening imaging studies.

1539 Background: Over 50% of South African women with breast cancer (BC) are diagnosed at stages III & IV. To inform an Implementation Mapping process to design strategies for implementing screening clinical breast exam (CBE) in primary care facilities in Soweto, South Africa, we gathered qualitative data from local primary care providers and patients on barriers to CBE and possible implementation approaches. Methods: We conducted semi-structured interviews with administrators, nurses, doctors, and community health workers (CHWs) and focus groups with women potentially eligible for screening CBE at four Soweto primary care facilities that do not offer BC screening. Our discussion guide explored BC screening perceptions among both groups. We also asked providers for recommendations about how to best implement a future CBE screening program, and we asked patients about factors that would motivate them to participate in such a program. We analyzed transcripts deductively in parallel with data collection. We organized themes using the Consolidated Framework for Implementation Research (CFIR). To support Implementation Mapping’s emphasis on addressing the needs of individual stakeholders, our analysis focused on the CFIR Individuals domain and Characteristics subdomain taken from the COM-B system. Results: We analyzed 27 interviews with 8 administrators, 1 medical officer, 14 nurses, 3 CHWs, and 1 clerk, and 4 focus groups with 23 total women. Providers ( i.e., deliverers) and patients ( i.e., recipients) alike expressed enthusiasm for CBE’s potential to decrease BC mortality and morbidity. Both groups also cited CBE’s potential to overcome and counteract patients’ limited knowledge of breast health and BC symptoms. The primary barrier to CBE, according to both groups, is the high patient volume at public facilities. Providers described staff shortages limiting opportunity to perform CBE and patients cited long wait times as a barrier to pursuing “extra” services. Providers often recommended hiring new personnel designated for CBE screening. Patients suggested various approaches to expanding access, such as screening in both the clinic and community, opportunistic screening while patients wait for other clinic services, and walk-in access for “screening only” visits. Patients also emphasized the need to improve trust in the clinics and their staff. Regarding educational outreach, providers focused on expert-delivered teaching in both the clinic and community. Patients valued experts but also recommended engaging BC survivors and other community members to promote screening through word-of-mouth. Conclusions: Soweto’s primary-care clinicians and patients expressed enthusiasm for the health benefits of BC screening, but successful implementation must address barriers faced by both groups, including long clinic wait times and personnel shortages.

Despite national primary care access challenges, some women receive primary care from both general medicine and obstetrics-gynecology (ob/gyn). The extent and potential implications of this phenomenon are unclear. To evaluate primary care use among US women and identify characteristics and service receipt associated with visits to both general medicine (e.g., general internal medicine, family medicine, pediatrics, geriatrics) and ob/gyn. Retrospective descriptive study using 2012, 2017 and 2022 data from the nationally representative Medical Expenditure Panel Survey. Non-pregnant women aged 19–85 years. Visit pattern (visits to general medicine only, ob/gyn only, both, another specialty only, no visits), usual source of care, service receipt. Of 9,297 respondents (weighted = 125,485,789), 29.2

BACKGROUND:Late-stage breast cancer contributes to a growing number of deaths in sub-Saharan Africa (SSA) but few studies examine scalable early detection strategies. Following small-scale pilots, in 2020 Rwanda launched an adapted Women's Cancer Early Detection Programme (WCEDP), integrating clinical breast exam (CBE) for symptomatic patients with cervical cancer screening. A WCEDP-specific electronic health record (EHR) was developed to facilitate patient tracking. METHODS:We used the RE-AIM implementation science framework to retrospectively evaluate implementation of breast cancer early detection within the WCEDP over 12 months in the first three scale-up districts (population: 2 009 888), using routinely-collected electronic and paper data from 15 health centres and 3 hospitals. We examined the WCEDP's Reach in the target population, Effectiveness linking patients to care, Adoption by facilities and fidelity to the Implementation protocol. RESULTS:Regarding Reach, average weekly health centre visits for CBE increased from 18 to 33 post-WCEDP launch; of 1688 women receiving CBE through the WCEDP, 12.0% were ≥50 years. Regarding effectiveness, among 383 women referred to district or referral hospitals, 157 (40.9%) had no documented referral facility visit. Of those seen at a referral facility, median days from health centre to district hospital visit and from district to referral hospital visit were 6 (IQR 1.8-14.8) and 8 (IQR 5.0-40.5) respectively. Among the 36 patients receiving biopsy, 72.2% were biopsied within 60 days of initial presentation. In terms of adoption, 79 clinicians were trained in cancer early detection, with 69.6% remaining at WCEDP facilities after 3 years. Regarding implementation fidelity, WCEDP clinics were held 52.6% of weeks. EHR data quality was inconsistent, with half of patients seen at district hospitals for breast care lacking EHR documentation. INTERPRETATION:Breast cancer early detection services can be implemented in resource-constrained SSA health facilities. Integration with cervical cancer screening may be a promising strategy. However, investing in data systems is critical to support programme evaluation and high-quality care.

Understanding factors associated with successful high-risk breast health programs can aid in the development of similar initiatives. This study evaluated the impact of the Breast Cancer Personalized Risk Assessment, Education, and Prevention (B-PREP) program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Patients evaluated from January 2017 to September 2024 were retrospectively reviewed from a prospectively maintained database. The number of patients seen over time was used to measure “reach.” Chemoprevention uptake was used to measure “effectiveness.” We surveyed B-PREP clinicians and staff using the validated Program Sustainability Assessment Tool (PSAT), to assess factors associated with sustainability (“implementation” and “maintenance”). The study identified of 5972 B-PREP patients, 1860 (31.1

The National Comprehensive Cancer Network (NCCN) and American Cancer Society (ACS) endorse differing guidelines for screening breast imaging among young females with familial breast cancer risk not driven by a germline pathogenic variant (PV). We sought to characterize practice patterns in our high-risk breast clinic related to screening breast imaging in this population. We identified all females aged 25–39 years with a first- or second-degree relative (FDR/SDR) with breast cancer and estimated lifetime breast cancer risk of ≥ 20

BACKGROUND:Transportation barriers can hinder patients' access to timely cancer diagnosis and treatment, particularly in low- and middle-income countries. In Rwanda, where cervical and breast cancer burdens are high, support through transport stipends can alleviate transportation barriers and improve patient outcomes. This study aims to understand the experiences and perspectives of women beneficiaries and program personnel involved in Rwanda's Bugesera District transport stipend program. METHODS:Purposive sampling selected seventeen participants for in-depth interviews, including twelve women beneficiaries and five program personnel. Document review and household visits provided context. From September 2021 to May 2023, 204 women attended follow-ups for cervical and breast cancer screening and 75% of them received transport stipends. RESULTS:Five themes emerged from beneficiaries' interviews: financial difficulties in accessing transportation for cancer care, impact of transport stipend on access to cancer services, barriers faced during transportation to cancer services, challenges in the process of receiving transport stipend, and recommendations to overcome stipend provision challenges. Five themes emerged from program personnel's interviews: impact of transportation stipend on access to cancer services, challenges in the process of providing transport stipend, recommendations to overcome stipend provision challenges, recommendations for implementation of transport stipend in other settings, and sustainability. CONCLUSIONS:The stipend was found to be impactful, but challenges in the provision process, including communication and delays, were identified. Insufficiency of the stipend was highlighted, with recommendations to expand coverage to other expenses. The study highlights the role of transport stipends in improving cancer early detection and linkage to needed follow-up and recommends strong partnerships and funding for program replication and sustainability. These findings can inform the planning of similar programs in low-income countries of Sub-Saharan Africa.

PURPOSECancer deaths in low- and middle-income countries (LMICs) will nearly double by 2040. Available evidence-based interventions (EBIs) for cancer prevention and early detection can reduce cancer-related mortality, yet there is a lack of evidence on effectively scaling these EBIs in LMIC settings.METHODSWe conducted a scoping review to identify published literature from six databases between 2012 and 2022 that described efforts for scaling cancer prevention and early detection EBIs in LMICs. Included studies met one of two definitions of scale-up: (1) deliberate efforts to increase the impact of effective intervention to benefit more people or (2) an intervention shown to be efficacious on a small scale expanded under real-world conditions to reach a greater proportion of eligible population. Study characteristics, including EBIs, implementation strategies, and outcomes used, were summarized using frameworks from the field of implementation science.RESULTSThis search yielded 3,076 abstracts, with 24 studies eligible for inclusion. Included studies focused on a number of cancer sites including cervical (67%), breast (13%), breast and cervical (13%), liver (4%), and colon (4%). Commonly reported scale-up strategies included developing stakeholder inter-relationships, training and education, and changing infrastructure. Barriers to scale-up were reported at individual, health facility, and community levels. Few studies reported applying conceptual frameworks to guide strategy selection and evaluation.CONCLUSIONAlthough there were relatively few published reports, this scoping review offers insight into the approaches used by LMICs to scale up cancer EBIs, including common strategies and barriers. More importantly, it illustrates the urgent need to fill gaps in research to guide best practices for bringing the implementation of cancer EBIs to scale in LMICs.

US Preventive Services Task Force; Wanda K. Nicholson, MD, MPH, MBA; Michael Silverstein, MD, MPH; John B. Wong, MD; Michael J. Barry, MD; David Chelmow, MD; Tumaini Rucker Coker, MD, MBA; Esa M. Davis, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Marie Krousel-Wood, MD, MSPH; Sei Lee, MD, MAS; Li Li, MD, PhD, MPH; Carol M. Mangione, MD, MSPH; Goutham Rao, MD; John M. Ruiz, PhD; James J. Stevermer, MD, MSPH; Joel Tsevat, MD, MPH; Sandra Millon Underwood, PhD, RN; Sarah Wiehe, MD, MPH

Background: Out-of-pocket costs are burdensome for breast cancer patients. Cost-reducing interventions, though implemented, have unclear comparative efficacy. This study aimed to critically evaluate characteristics of successful versus unsuccessful interventions designed to decrease out-of-pocket costs for breast cancer patients. Methods: A systematic review was conducted in accordance with the PRISMA checklist. Embase, PubMed, Global Index Medicus, and Global Health were queried from inception to February 2021. Articles describing a financial intervention targeting costs for breast cancer screening, diagnosis, or treatment and addressing clinical or patient-level financial outcomes were included. Methodological quality was evaluated using the QualSyst tool. Interventions were organized in accordance with timing of implementation, with narrative description of intervention type, success, and outcomes. Results: Of the 11,086 articles retrieved, 21 were included in this review. Of these, 14 consisted of interventions during screening, and seven during diagnosis or treatment. Free/subsidized screening mammography was the most common screening intervention; 91% of these programs documented successful outcomes. Patient navigation and gift voucher programs demonstrated mixed success. The most successful intervention implemented during diagnosis/treatment was reducing medication costs. Low-cost programs and direct patient financial assistance were also successful. Limitations included lack of standardization in outcome metrics across studies. Conclusions: Financial interventions reducing prices through free screening mammography and decreasing medication costs were most successful. Less successful interventions were not contextually tailored, including gift card incentivization and low-cost treatment modalities. These findings can facilitate implementation of broader, more generalizable programs to reduce costs and improve outcomes during evaluation and management of breast cancer.